Medical Claims Review Manager oversees the performance, productivity, and quality of the medical claims review staff. Responsible for hiring, training, and firing medical claims review staff. Being a Medical Claims Review Manager evaluates medical claims review processes and recommends process improvements. Serves as a technical resource for all medical review workers. Additionally, Medical Claims Review Manager typically requires an RN or BSN. Requires a bachelor's degree. Typically reports to a head of a unit/department. The Medical Claims Review Manager manages subordinate staff in the day-to-day performance of their jobs. True first level manager. Ensures that project/department milestones/goals are met and adhering to approved budgets. Has full authority for personnel actions. Extensive knowledge of department processes. To be a Medical Claims Review Manager typically requires 5 years experience in the related area as an individual contributor. 1 to 3 years supervisory experience may be required. (Copyright 2024 Salary.com)
Must have High school diploma, GED or equivalent required, Two year degree preferred.
Minimum of 3 years previous experience working for a Health Plan, IPA, or other Managed Care Organization.
Minimum of 2 years previous direct experience that included verifying and maintaining provider information and provider contract configuration in a managed care transaction system.
REQUIRED EXPERIENCE:
High school diploma, GED or equivalent required, Two year degree preferred.
Minimum of 3 years previous experience working for a Health Plan, IPA, or other Managed Care Organization.
Minimum of 2 years previous direct experience that included verifying and maintaining provider information and provider contract configuration in a managed care transaction system.
Working knowledge of one or more of the following managed care transaction systems: EPIC (Tapestry Module), EZ Cap, Facets, QNXT.
Working knowledge of CPT-4, ICD-9/ICD-10, and HCPCS codes.
Must have the ability to interpret a variety of instructions furnished in written, oral, diagram and schedule form including provider contracts and contract summaries.
Ability to adhere to detailed data entry procedures in a complex Managed Care Transaction System with high accuracy for alpha and numeric data inputting.
Strong organizational skills and the ability to manage aggressive timelines and prioritize multiple concurrent tasks while maintaining high quality standards.
Proficient computer skills including Microsoft Excel and Word. Competence in navigating the internet.
Excellent customer service and interpersonal skills, with an ability to work with internal and external representatives
Willingness to learn new technologies, practices and procedures
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